health assessment practice questions

Correct Answer: C

Rationale: The correct answer is C: drooping of the upper eyelid. Ptosis refers to the drooping of the upper eyelid, which may occur due to weakened eyelid muscles or nerve damage. In this case, the nurse suspects ptosis in the 60-year-old man, which is likely due to age-related muscle weakness. Choice A, a cloudy cornea, is incorrect as it refers to a different eye condition. Choice B, an unequal red reflex, is incorrect as it is related to abnormalities in the retina. Choice D, protruding and bulging eyes, is incorrect as it indicates exophthalmos, a condition typically seen in thyroid eye disease.

Correct Answer: C

Rationale: The correct answer is C because stimulation of the sympathetic branch of the autonomic nervous system results in the elevation of the eyelid (ptosis) and dilation of the pupil (mydriasis). This is due to the action of the dilator pupillae muscle and the superior tarsal muscle. Pupillary constriction (choice A) is controlled by the parasympathetic branch via the sphincter pupillae muscle. Adjusting the eye for near vision (choice B) is controlled by the ciliary muscle, which is under parasympathetic control, not sympathetic. Contraction of the ciliary body (choice D) is also controlled by the parasympathetic system for accommodation of near vision, not the sympathetic system.

Correct Answer: C

Rationale: The correct answer is C: Dysphagia. In a stroke patient with right-sided facial drooping, dysphagia is highly likely due to the involvement of the facial nerve, leading to difficulty swallowing. Epistaxis (A) is nosebleeds, agenesis (B) is the absence of a body part, and xerostomia (D) is dry mouth, which are not directly related to facial drooping in stroke patients. Dysphagia is a common complication post-stroke due to impaired muscle control, making it the most likely concern for the nurse to suspect in this case.

Correct Answer: C

Rationale: The correct answer is C: Tilt the child's head slightly toward the examiner. This position straightens the ear canal, facilitating visualization. Pulling the pinna down (A) can cause discomfort and obstruct the view. Pulling the pinna up and back (B) is incorrect for a child under 3 years old as it straightens the ear canal in adults. Having the child touch his chin to his chest (D) is unnecessary and may lead to improper examination positioning.

Correct Answer: B

Rationale: The correct answer is B: This is a bifid uvula, which is a common occurrence in some Aboriginal groups. 1. A bifid uvula is a condition where the uvula is split or divided, which is a common variation seen in some Aboriginal populations. 2. Cleft palate is a different condition involving a gap in the roof of the mouth, not specifically related to Aboriginal people. 3. Uvular injury is not a common cause of a split uvula in children, so reporting to authorities is unnecessary. 4. Torus palatinus is a bony growth on the roof of the mouth and not related to a split uvula or specific to Aboriginal populations.